Documentation Toolkit

๐Ÿ”— Links
๐Ÿ“Š Clinical Scores
๐Ÿšจ Sepsis Flowcharts
๐Ÿฆต Wells DVT Score Calculator
Active cancerTreatment or palliation within 6 months
Bedridden recently >3 days or major surgery within 12 weeks
Calf swelling >3 cm compared with the other legMeasured 10 cm below tibial tuberosity
Collateral (non-varicose) superficial veins present
Entire leg swollen
Localised tenderness along the deep venous system
Pitting oedema, confined to symptomatic leg
Paralysis, paresis, or recent plaster immobilisation of the lower extremity
Previously documented DVT
Alternative diagnosis to DVT as likely or more likely
Total: 0 โ€” DVT unlikely
๐Ÿซ Wells PE Score Calculator
Clinical signs and symptoms of DVT
PE is the most likely diagnosis, or equally likely
Heart rate >100 bpm
Immobilisation for โ‰ฅ3 days or surgery in previous 4 weeks
Previous objectively diagnosed PE or DVT
Haemoptysis
MalignancyTreatment within 6 months or palliative
Total: 0 โ€” PE unlikely
Obs, Neuro & Pain
Auto NEWS2 Score: 0
Midstream Urine Dipstick
Urine Dipsticks for patients aged 65yo+ should not be used for Nitrites/Leukocytes to diagnose UTI (NICE, 2023) due to asymptomatic bacteriuria.
Neuro assessment - not included in NEWS2
Pain assessment - not included in NEWS2
Abbey Pain Score - not included in NEWS2

Clinical Use Disclaimer: This toolkit is an independently developed documentation aid and is not an official clinical system or a substitute for clinical assessment, professional judgement, local or national guidance, or appropriate escalation.

Clinical tools, scores, templates, prescribing information and safety-netting prompts must be independently verified and applied appropriately to the individual patient.

Users remain professionally responsible for the accuracy, completeness and appropriateness of their documentation, prescribing and clinical decisions.

Neither the developer nor the user's employer, commissioning organisation or healthcare provider accepts responsibility for errors, omissions, inappropriate use, or clinical decisions made using this toolkit.

Always review and verify generated documentation before adding it to the clinical record.

Information Governance: This toolkit processes entered information locally within your web browser. It does not transmit, save or retain patient information, including when the toolkit itself is hosted online. Information entered into the form is not stored by the toolkit and should only be copied into an approved clinical record system in accordance with your organisation's information-governance requirements.

Documentation Toolkit Version 5.3.43 GEN Last updated: 15 August 2026
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